Question

Difficulty: EasyPatient Safety and Quality Improvement

Match each clinical safety incident described below to the correct patient safety error classification.

  • A pharmacist intercepts and cancels a newly prescribed antibiotic order after noting the patient's documented severe allergy.Near miss
  • A resident physician calculates the incorrect weight-based dosage of a medication and writes the prescription.Active error
  • A hospital uses identically shaped and colored vials for two high-risk medications stored in the same bin.Latent error
  • A patient undergoes an invasive surgical procedure on the incorrect side of their body, leading to permanent loss of function.Sentinel event

Answer

The intercepted allergy order is a near miss. The incorrect dosage calculation is an active error. The identical medication vials represent a latent error. The wrong-site surgery is a sentinel event.
Each incident maps uniquely to an error classification based on whether the error reached the patient, the severity of the outcome, and whether it was a frontline action versus a system flaw.

Step-by-Step Solution

1
Analyze the intercepted antibiotic order.
The error was caught by the pharmacist before reaching the patient.
Events that have the potential to cause harm but are intercepted before reaching the patient are classified as near misses.
2
Analyze the resident's dosage miscalculation.
The error occurred directly at the point of care by the human operator.
Errors committed directly by frontline personnel (e.g., physicians, nurses) are classified as active errors.
3
Analyze the identically colored vials.
This is a systemic design flaw waiting to cause harm.
System-level vulnerabilities, such as poor equipment design or unsafe storage policies, are known as latent errors.
4
Analyze the wrong-side surgery.
This event caused severe, permanent patient harm.
Adverse events involving death or serious physical or psychological injury are classified as sentinel events.

Key Concept

Classification of patient safety incidents (active error, latent error, near miss, sentinel event)
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